This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Friday, 21 September 2007

Which One is the Nurse? Does It Matter?

Yes it does actually.

Time to go off on a few tangents and let off steam. It's theraputic for me even if no one reads this longwinded crap.

Before I start I would like to deal with a misconception about highly educated nurses. People think that we think we are above bedpans and cleaning. This is just not true.

I have always said that the major problem with Nursing is this: People don't understand what a nurse is, what nurses do, how much they have to know, the amount of liability and accountability they take on, the amount of education they need to do their jobs, and the unbelievable amount of responsibility they have. They cannot differentiate between a Registered Nurse and a Nursery "nurse" and probably think they have the same level of education.

How do I know that the public is so freaking clueless? Because I read doctor blogs and then I hear people refer to their 17 year old niece who gets a job working in the hospital as an auxillary as "a junior nurse". Yeah. A Nurse. Yep. People think that employee who comes into their room to take a blood pressure is a nurse. Why did I work so hard to get the initials RN behind my name if people think that the trolley girl who serves tea is a nurse? Any female walking around the hospital in uniform is a "nurse". This is totally unnacceptable. If you analyze this further you can see some of the serious problems that can arise as a result of ignorance. Attitudes can Kill.

You think I am being petty? Walk into an airport and call an airline pilot "stewardess". Hell they all work in the same place so whatever right? Walk into a solicitors office and refer to the legal secretary as "solicitor"..why not they all work in the same place. Walk into a hospital and call the doctor "nurse". You all know not to do this yet you refer to an untrained but well meaning kid who simply makes beds and walks people to the toilet as "nurse" which is my legal title and I'm not supposed to get annoyed? If an HCA or an auxillary had to go through what I went through in nursing school they would probably flunk out. Yes I know I sound too much like Dr.Crippen when he is having one of his quacktitioner vs Doctor tantrums.

They (support staff) know that real nursing is a total bitch. Why do you think so many of them won't go off and become nurses even though their education would be free (in the UK) and they would make slightly more money? Why do all that work when one can have an easier (although backbreaking) job with no accountability and still get called "nurse". They are only on very slightly less than an actual nurse salary wise. The job is lightyears less demanding...even if they are breaking their backs doing all of the lifting, bathing, turning etc. I was an HCA once so I know the score. I used to think that HCA's did all the work and now I look back on that knowing what I know now and realise that I was just ignorant.

I worked my ass off through a rigorous 4 years at university where I was in lectures 8-12 hours a day and clinical placements on top of thaton the same damn day. I had to take university level chemistry, microbiology, anatomy and physiology 1 and 2, statistics, the pharmacology course from hell, and much more as well as nursing theory. The other students at this university could get shit grades barely above passing and still graduate but the nursing majors were kicked out if their final grade for any class went below an 80%. Two fuck-ups in clinical and you were gone and you didn't get your $40,000 a year tuition refunded. Okay I was on a full scholarship but I was still under an insane amount of pressure. While I was doing 8 hours of clinical a day on top of 8 hours of lectures in a single day the media studies majors were getting drunk and fucking around. Bastards make more money than me too.

We were going to be nurses and had to be better than the others. This is what we were told. Nurses have life and death responsibility and even small mistakes kill. Most other Uni grads won't have to deal with that or work in such a chaotic environment. They won't have to think as fast etc etc.

Nursing in the UK is no piece of cake either. There are two ways of becoming a registered nurse. One can either do a 3 year diploma AT UNIVERISTY, or a 3-4 year degree AT UNIVERSITY. Let me tell you something. The 3 year diploma is a lot tougher in many ways than your typical 4 year degree for non-healthcare staff at university. Any starting new grad RN walks into a job where he will have triple the responsibility and workload and accountability that a teacher, english major, or business major etc. will have. I have lost count of the number of people I know who have done nursing as a second degree and said it was shockingly harder than their first degree. They don't last long.

I have lost count of the people I know who have Bachelors degrees in other fields who have flunked out of diploma nursing. In places like the USA where an RN has a highter starting salary than most new grads we see engineers, teachers, accountants, computer majors and others going back to Nursing school because they want a higher paying job and they want to help people. In the UK we see people who go through some kind of mid-life and decide to switch careers into nursing because they feel that they have done nothing worthwhile with their other degree and they want a job that means something...they want to help people.

What do all of these people have in common? The vast majority feel that nursing school was the toughest thing they ever did yet it was cake compared to actually trying to function as a staff nurse on a general ward. I know 5 school teachers (2 with a masters degree who went back to nursing school. Three were located in the USA where nurses make more money and 2 were located in the UK where nurses make less money than a teacher. Only 2 of them actually made it through nursing school and none of them lasted more than a year as nurses. They were soon back to teaching and it wasn't because they have an aversion to shit and puke. They couldn't handle the information overload and the life and death responsibility, the nightmarish hours. The ones in the US took the pay cut and went back to teaching.

Sure nursing education is lacking in a lot of ways but it's a lot harder than you think believe me. Just because it isn't as hard and as long as medical school doesn't mean it is cake. Nurses need a good academic foundation as well as massive amounts of hands on training done IN THE RIGHT WAY. Years ago we had the latter and not the former. People died. Now we have the former but not the latter. People die. My belief is that nurses do need to have a 4 year degree as entry level BUT that doesn't mean shit without decent placements and mentoring and interships. You just can't have one without the other. You need both. But who wants to go to school that long to get paid less than a policeman?

In spite of these problems with nurse education, people who can legally call themselves nurses have worked hard to earn it. The 19 year old HCA who makes your bed has no idea what it takes to be a nurse. They have no accountability and don't have to make difficult decisions. They don't take responsibility for anything. They are working on my license. They do not understand all of the ins and outs of what I am doing and why. They hear in report that we have a patient with an HB that dropped fairly quickly who is still on 2 kinds of anti-coagulants for that clot and he now has maleena. He is in the bed next to the NBM guy who now has no IV access and a K+ of 1.9. I have to change some info here to comply with confidentiality but you get my drift. They hear these things but they don't know what that means or what's involved and they don't understand why I make a run for those guys as soon as I get out of report rather than "helping us" serve breakfast.

Even after completely 4 years of hell at Uni and graduating with a degree in Nursing I was STILL NOT LEGALLY ALLOWED TO CALL MY SELF A NURSE. I had to take a miserable hellish state board exam. I passed on the first go and then I was allowed to use the term nurse to describe myself without breaking the law for the first time. All this qualified me to apply for a job as a Junior D grade staff nurse in the UK. I paid my dues to the state board of nursing for my license and than the NMC. It costs money to maintain a license. Not an issue for support staff.

This unfuckingbelievable amount of ignorance regarding nurses, their legal responsibilities and their education leads to many things. Indirectly it leads to people suffering and getting shitty care.

First of all it's very easy for the powers that be to cull back the number of registered nurses and bring in untrained kids with nose rings, give them a uniform and teach them how to make a bed. The public doesn't really understand the difference between these employees and a "nurse". Their opinion of nursing as a profession goes out the bloody window. I have heard comments such as "an HCA does everything a nurse can do except give meds". You have got to be shitting me. I'll be writing about a day in the life of an RN in a later post and we'll discuss this.

This increase in non-professional staff and decrease in actual nurses is occuring at a time when patients are sicker and more complex due to advances in health care that SAVE THEIR LIVES, as well as increasing targets that cause us to have to run around like chickens with our heads cut off rather than focus on the task at hand. The liability and the litigation against nurses is increasing causing us to spend more time than anything covering our asses via documentation. If you didn't document it...than you DIDN'T DO IT. That is the rule and if you don't adhere to that you GET BUSTED.

Meanwhile the HCA's are spending most of the time doing patient care (i.e assistance with activities of daily living). I don't have a choice but to let that happen because I am so overwhelmed but it scares the living fuck out of me. If I bathed my own patients, fed them, and walked them to the loo I can do a hell of a good holistic nursing assesment during that time and decrease the risk of getting fucking slaughtered by the NMC. I will notice how you are breathing while bathing you. An HCA will not or may not connect any dots. I will notice if you are showing signs of internal bleeding, shock, neurological changes, drug reactions, dehydration, pneumonia, hypoxia, infection, etc etc etc ad nauseum. I will catch problems during this time and sort them. An HCA will bath you and go onto the next patient because she doesn't know any better. Does the term "Failure to rescue" sound familiar? Most HCA's are lovely and hardworking but they do not have a license or professional accountability. If they fuck up I am fully responsible. They can't connect the dots between your appearance on a good head to toe assesment and your meds, labs, etc.

Am I able to provide basic care and do a good nursing assesment of each of my patients during this basic daily activity? NO.

Am I forced to dump things like bed baths on the HCA's? Yes.

Does that mean that my patients problems are not getting noticed quick enough? Yes.

Are nurses happy about this? Hell No.

We are scared shitless. Doing simple bedbaths allows me to do a thorough assesment that can help a patient, catch trouble brewing and keep my cute little bottom out of trouble. We are not "too posh to wash". We are "pulled in too many directions at once to wash" and we hate this because we can't get a good handle on our patients general condition which leaves us open to litigation, as well as a lifetime of guilt. Plus you just look fucking stupid when you don't know that your patient has sore heals. a sacral sore and a cellulitic looking leg and you have been "caring" for him 2 shifts in a row.

In later posts I will talk about nursing assesments how much I learn about your general condition during a 2 minute chat and a bedbath, or a simple walk to the toilet. That assesment at the beginning of my shift can make or break you (and me). I believe that all care should be carried out by an RN with a small number of patients. I believe that I should have a smaller number of patients and do everything for them from hanging IV meds, assesments, care-planning, to wound care, and to cleaning their damn feet. Pedal pulses anyone? This is how I feel and yet I have no choice but to leave the bathing and the mobilizing and the talking to my patients to the HCA's. No choice whatsoever.

Where are the signs of horror regarding low patient ratios and a mass exodus of actual nurses from the bedside? Why doesn't the public care? Why aren't they worried and crying out regarding the dangers of short staffing? Because to them a nurse is simply the hospitals version of waitressing staff, and doctors (who are rarely ever on the wards) are somehow watching the nurses' every move and the patient's condition. Therefore nursing care is really no big deal.This is what sets the stage for poor care in hospitals. Nurses are an easy target for managers, and we are one of the first things to get culled back when they need to balance the books. Until people realize just how important nursing care is and that we need lots of actual nurses around care will continue to deteriorate.

18 comments:

Nurses are the eyes and ears of the hospital. Think of this situation. Actually I have had this analagy locked and loaded for my own blog but have not yet needed to use it so here goes Anne ;-)

A patient comes into hospital and presents in A&E feeling unwell, weak and short of breath. A NURSE takes baseline observations which reveal a bradycardia of 41 BPM. The patient falls unconscious and the DOCTOR prescribes Atropine 0.6mg. The NURSE administers the drug and the patient returns to a normal sinus rhytum and a puls of 75 bpm. The patient regains consciousness and he turns to the DOCTOR and the NURSE and says "Which ONE of you two saved me?".

Was it the doctor by diagnosing or the nurse through physically administering the atropine? Discuss.

That is why I truly believe that nurses are left undervalued. There is lack of media focus on the hopsital profesionals and the public are largley uncaring of it. It really is soul destroying. However, my background is with ambulances, and it really winds people up when they call ambulance staff all "Drivers" or simlply called crews "the ambulance".

However, I will be up at 05:30 this morning to go back to all the problems of the ward. And do you know something? I absolutly bloody love every minute of it :-)

wow thanks for that, for the first time I really understand why qualified nurses should do the basic care stuff as well. I also know why I won't be demanding that they do it, if i go back into hospital- because the really sick guy in the bed next door, is going to need them more than me. It's hard for those of us outside the medical profession to make any kind of reasonable assessment of who / why x person with x qualification should do any particular kind of job or not, even whenwe want to.

I get treated (brilliantly) by a prescribing nurse practitioner at my local GP surgery. It was months before I realised they were an NP not a GP. When I did find out, I wasn't the least bit concerned, they wouldn't let them do this if they weren't competent right? and to be honest I really liked their approach (that combination of nurse come doctor is is a good one) Then I read Dr Crippen, had a few doubts and decided to find out if NP's really were the same as GP's etc. Whats the result; I still havn't got a clue. Will I still see the NP, yes, if nothing else they make me feel calm and confident.

What i'm getting at is, that until the medical profession makes it clear who is who, and what their role is / should be, the patients probably won't have a clue - even when they've tried to find out. The maze that is the NHS is hard to negotiate when you have no medical training - how do i know what level of competency the person taking me to the toilet has or needs?

Keep posting this kind of stuff, patients don't have a hope of finding out what's going on otherwise!

I do agree with you, but I think that you're unfairly critical of HCAs, rather than the management that is putting them in positions where qualified staff are needed.

"First of all it's very easy for the powers that be to cull back the number of registered nurses and bring in untrained kids with nose rings, give them a uniform and teach them how to make a bed".

Firstly, I've worked (as a HCA) with plenty of qualified, experienced and shit hot nurses with nose rings, so I'm not sure how that matters. Secondly, I think 'kids' is a bit unfair, seeing as a good proportion of HCAs are middle-aged women with children, scraping by on Band 2, working bank shifts on their days off.

There's plenty of reasons other than laziness that HCAs don't train as nurses - money, lack of confidence, lack of academic skills. And loads of HCAs do train up, do learn their stuff and put the hours in. I started off as a HCA with no healthcare experience, and now I'm training as a paramedic. I'm writing essays, making decisions and working my arse off on the ambulances.

HCAs could be a valuable resource, but they're abused by managers wanting to save money. It's unfair on the HCAs expected to work untrained (I never received moving and handling training in the 8 months that I was a HCA, never learned about dealing with vulnerable or abusive patients, never received formal training on... well, anything.) and it's unfair on the nurses too. But if qualifieds start taking it out on the HCAs then we're in an even worse situation - a little bit of solidarity goes a long way. And we're all in the fucking car crash that is the NHS together.

about how bad I feel for the these kids and what happens when they are left in way over their heads.

I still don't think that an HCA is under the pressure that a nurse is. First of all, if an HCA screws up, the nurse gets it in the neck. The care assistant does not have a license to lose. Second of all, even if the HCA is working her ass off washing patients, doing observations etc 99% of what is going on in that ward is still over her head. They don't realise what the nurses have on their shoulders. They don't even pay attention to 90% of what is said in handover.

Our cadets and care assistants do not want to go on to train as a nurse. They aren't too lazy or stupid to become nurses they are just too scared. The know they have the better deal as non nurses even if the pay is less. They don't have the responsibility, they don't ahve to stay over 4 hours unpaid past the end of their shift, and everyone just thinks that they are a nurse anyway.

It is frightening to work with a new, inexperienced nursing assistant who confidently 'explains' that respiration is simply the patient's chest moving up and down and who will not listen when you try and emphasise why it is so important.

Ignore this if you are a good support worker but if not, read on. When you are working with me please do not snatch fluid charts out of my hand, wave them about and announce to the whole ward that they have not been filled in today (when they have) because it embarrasses me and makes me angry. Please do not follow me around like a shadow checking up on me in the hope you can tell tales - concentrate on your own work please. Kindly do not interrupt and ask if everything is alright when I am having a private conversation with a relative - it is not your place, remember? (Incidentally the relative glowered darkly and said "I've had trouble with that one myself" - just thought you'd like to know.) Do not try to be clever and correct me in front of patients because you are ignorant (in both senses of the word). When I ask you pleasantly to do a job for me do you think that for once you could smile and say "yes, no problem" instead of glaring mutinously - it is after all what you are paid for. You seem jealous. If that is the case why not apply to train? What's that you say? Oh, you are not academic and don't want all that responsibility. Well dear you can't have your cake and eat it can you? So, I will ask you nicely just once more - please get off my case and show me a little R-E-S-P-E-C-T (just a little bit)or I am going to blow a fuse!

If you feel that your patients are at risk and your support staff are poorly trained......Stop blathering on in a blog and take action!You, as a registered Nurse should be researching, costing and implementing the appropriate Training for your Support staff or refusing to work in a situation that endangers patients.Sheesh, stop banging on about your Degree and get some common sense. Sadly, that's a skill that can not be taught at university. Remember, Education is one thing, Intelligence is another. The two do not all ways go hand in hand!

Re. 20th August comment. What blathering on? I didn't mention anything about having a Degree. Anne mentions her Degree occasionally - good for her. How do you know I have one? Never assume! Actually I have two. I will try to remember that education is one thing and intelligence is another - I will pass these pearls of wisdom on to the next group of University students I teach. Qualifications are one thing and courtesy is another. There is a lack of the latter in the NHS as the rude tone of your response proves. The old saying that it is nice to be important but it is more important to be nice is very true.

Re. 20th August comment. What blathering on? I didn't mention anything about having a Degree. Anne mentions her Degree occasionally - good for her. How do you know I have one? Never assume! Actually I have two. I will try to remember that education is one thing and intelligence is another - I will pass these pearls of wisdom on to the next group of University students I teach. Qualifications are one thing and courtesy is another. There is a lack of the latter in the NHS as the rude tone of your response proves. The old saying that it is nice to be important but it is more important to be nice is very true.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.